Failure to Complete Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Level II Pre-Admission Screening and Resident Review (PASRR) was completed for five residents who were sampled. These residents had various diagnoses, including serious mental illnesses and neurocognitive disorders, which necessitated a Level II PASRR evaluation according to the guidelines. However, the facility did not complete these evaluations, as evidenced by the records and interviews conducted during the survey. Resident #48 was admitted with diagnoses including PTSD, unspecified dementia, and substance abuse, with major depressive disorder added later. The Level I PASRR screen indicated the need for a Level II evaluation due to the presence of a serious mental illness alongside dementia, but this was not completed. Similarly, Resident #29, diagnosed with paranoid schizophrenia and other mental health conditions, did not receive a Level II PASRR despite the chronic nature of their mental illness. Other residents, such as Resident #6, #13, and #2, also had significant mental health diagnoses that warranted a Level II PASRR evaluation. These included conditions like dissociative identity disorder, bipolar disorder, and schizoaffective disorder. The facility's policy required that such evaluations be conducted when indicated by the Level I screen, but the necessary referrals and evaluations were not made. Interviews with the Social Services Director and Director of Nursing revealed a lack of awareness regarding the need to complete these evaluations, contributing to the oversight.
Plan Of Correction
1. Social services director submitted a Level II PASRR request for resident #48 on #13, resident #29 on, resident #6 on, and #2 on. 2. The Social services director will audit residents who have a diagnosis of SMI, ID, and/or related in the facility and if warranted, will submit for level 2 PASRR screen by. 3. Reeducation was provided to the IDT team on the Level II PASRR screen process by NHA or designee on. Ongoing, new admissions to the facility with diagnosis of SMI, ID, and/or related will be audited by social services director or designee within 72 hours of admission for presence of level 2 PASRR screen and submit if warranted. IDT will conduct quality assurance check weekly for 12 weeks on provider documentation to identify any additional diagnoses requiring a level 2 PASRR screen to be initiated. 4. All results of the quality assurance checks/audits will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.